The surgical management of rectovaginal fistulas remains a source of frustration, as they tend to be recurrent and difficult to address, with widely variable location and severity. We present a case of a 63-year-old woman with a low-lying rectovaginal fistula. She initially underwent chemoradiation and a Low Anterior Resection for a low-lying rectal cancer. Her course was uneventful until two years post-operatively, at which time the staple line became stenotic with associated bleeding. This was initially addressed by Gastroenterology, who executed a dilation and achieved hemostasis with Argon Plasma Coagulation. This remedied the stenosis, however, it was complicated by the formation of a rectovaginal fistula. Due to the low lying location, and its presence in an irradiated field, a transvaginal approach with an interposed gracilis flap was elected for repair.
The patient was positioned in lithotomy in order to permit a transvaginal approach to access the fistula. The posterior fourchette of the vagina was incised, and a plane was developed between the rectum and vagina. This allowed the fistulous tract to be identified and excised. Additionally, the defect in the rectum was located and repaired. Following this, Plastic Surgery harvested and tunneled a vascularized gracilis flap into the field to buttress the repair. Finally, a diverting loop ileostomy was created, with a planned reversal in 3-6 months. Post-operatively, the patient recovered well and her ileostomy was reversed in 3 months with maintenance of full continence of bowel and bladder, with no further signs of communication between her rectum and vagina.